| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||
| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** **PAD** 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| True Label | Predicted Label | Attribution Score | Word Importance |
|---|---|---|---|
| admission date discharge date date of birth sex f service medicine allergies levofloxacin attending first name3 lf chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital3 hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to hospital1 for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin date range for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz date range ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol date range which had to be uptitrated for sedation she was transferred to hospital1 on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h initials namepattern4 last name namepattern4 doctor last name syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence doctor last name protein immunofixation urine no definite m protein seen negative for bence doctor last name protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on initials namepattern4 last name namepattern4 giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for malignant cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with female first name un species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at telephone fax within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr last name stitle doctor last name 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary female first name un parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and female first name un species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr first name8 namepattern2 last name namepattern1 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at hospital1 the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for malignant cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is name ni name ni telephone fax h son is name ni name ni telephone fax c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily doctor first name d hospital1 flonase sprays eat nostril daily advair on inh hospital1 albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane hospital1 times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility hospital3 location un location un discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia female first name un parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd doctor first name doctor last name syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp first name8 namepattern2 last name namepattern1 following your discharge from rehab his office number is telephone fax please also schedule follow up with ob gyn on discharge from rehab the office number at hospital1 is telephone fax completed by | |||